Variceal bleeding – primary prevention

Cirrhotic patient
Refer to VESSPER (Variceal
Endoscopic Screening and
Surveillance Program)

Screening Upper
Endoscopy

Grade 2 or 3 varices or “Red

No Varices Grade 1 varices
Whale” markings

Child-Pugh Child-Pugh Class

Class A (see B or C (see below
below for scale) for scale)

Propranolol prophylaxis –
3-yearly Yearly Yearly Propranolol
no further endoscopy
screening screening surveillance contraindicated, not
(see below for dosage
endoscopy endoscopy endoscopy tolerated or non
details and
compliance
contraindications)

Endoscopic
variceal band
ligation 2 weekly
until eradication

Yearly
surveillance
endoscopy

Variceal Grading (BSG, 2001) Propanolol prophylaxis Severity of Liver Disease: Child-Pugh Score
Usual dose is 80-160 mg daily ---------------------------------------------------------------
Grade 1: Collapse with Category 1 2 3
oesophageal inflation Commence 40mg BD and aim for
---------------------------------------------------------------
(small) resting HR < 55 or 25% reduction in
Encephalopathy 0 I/II III/IV
resting HR Ascites Absent Mild/mod Severe
Grade 2: Between grades 1 and 3 Bilirubin (umol/l) <34 34-51 >51
(medium) Contraindications: heart failure, Albumin >35 28-35 <28
Grade 3: Occlude lumen (large) asthma, severe peripheral vascular INR <1.3 1.3-1.5 >1.5
disease, AV block, pulse <55, SBP<90 -----------------------------------------------------------------

Child-Pugh class A represents a score of 5-6,

class B 7-9, class C 10-15

References – BSG Guidelines, Gut 2001; AASLD Postgraduate course 2004

This protocol has been developed for FMC practice setting only. It is intended to guide practice and does not replace clinical judgement. Modification will
occur according to internal audit processes and literature review. Issued, March 05 by Gastroenterology and Hepatology Units. Due for review March 07
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